Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1067 (07/08)

STATE OF WISCONSIN

HEALTHCHECK / YOUR CHILD'S SPEECH AND HEARING
Instructions: Reach each question through the child's age group and check YES or NO. Add the total number of Nos. If you obtain two or more Nos within an age level, or three or more Nos in all age groups through the child's age group, refer for audiological and communicate screening / assessment.

Check One

YES

NO

Hearing and Understanding
Does your child listen to speech? Does your child startle or cry at noises? Does your child awaken at loud sounds? Does your child turn to you when you speak? Does your child smile when spoken to? Does your child seem to know your voice and quiet down if crying? Does your child respond to "No"?

Child's Age
BIRTH

Talking
Does your child make happy sounds? When you play with your child, does he / she look at you, look away and then look again?

Check One
YES NO

Does your child repeat the BIRTH TO THREE MONTHS same sounds a lot (cooing, gooing)? Does your child cry differently for different needs? Does your child smile when he / she sees you?

FOUR TO SIX MONTHS

Does your child's babbling sound more speech-like with lots of different sounds, including p, b, and m? Does your child tell you (by sound or gesture) when he / she wants you to do something again? Does your child make gurgling sounds when left alone? When playing with you?

Does your child react to changes in your tone of voice?

Does your child look around for the source of new sounds, e.g., the doorbell, vacuum, dog barking? Does your child notice toys that make sound? Does your child know words for common items like "cup", "shoe", and "juice"? Has your child begun to answer to requests ("come here", "want more?")? Does your child enjoy games like peek-a-boo and pat-a-cake? Does your child turn or look up when you call his or her name?

SEVEN MONTHS words (bye-bye, dada, mama, TO no) although they may not be clear? ONE YEAR
Does your child's babbling have both long and short groups of sounds such as "tata", "upup", "bibibibi"? Does your child copy different speech sounds? Does your child use speech or non-crying sounds to get and keep your attention?

Does your child say 1 or 2

Does your child listen when spoken to?

HealthCheck / Your Child's Speech and Hearing F-1067 (07/08)

Page 2

Check One

YES

NO

Hearing and Understanding
Can your child point to pictures in a book when they are named? Does your child point to a few body parts when asked? Can your child follow simple commands and understand simple questions ("Roll the ball," "Kiss the baby," "Where's your shoe?")? Does your child listen to simple stories, songs, and rhymes? Does your child understand differences in meaning ("go-stop"; "in-on"; "big-little"; "up-down")? Does your child continue to notice sounds (telephone ringing, television sound, knocking at the door)? Can your child follow two requests ("get the ball and put it on the table")?

Child's Age
1 ­ 2 YEARS

Talking
Is your child saying more and more words every month? Does your child use some 1-2 word questions ("where kitty?" "go bye-bye?" "what's that?") Does your child put 2 words together ("more cookie," "no juice," "mommy block")?

Check One
YES NO

Does your child use many different sounds at the beginning of words?

2 ­ 3 YEARS

Does your child have a word for almost everything? Does your child use 2-3 word "sentences" to talk about and ask for things?

Do you understand your child's speech most of the time? Does your child often ask for or direct your attention to objects by naming them?

Does your child hear you when you call from another room? Does your child hear television or radio at the same loudness level as other members of the family? Does your child answer simple "who," "what," "where," "why" questions?

3 ­ 4 YEARS

Does your child talk about what he/she does at school or at friends' homes? Does your child say most sounds correctly except a few, like r, l, th and s? Does your child usually talk easily without repeating syllables or words? Do people outside your family usually understand your child's speech? Does your child use a lot of sentences that have 4 or more words? Does your child talk easily with other children and adults? Does your child say all sounds correctly except maybe one or two? Does your child use the same grammar as the rest of the family? Does your child's voice sound clear like other children's? Does your child use sentences that give lots of details, e.g., "I have two red balls at home."? Can your child tell you a story and stick pretty much to the topic?

Does your child hear and understand most of what is said at home and in school? Does everyone who knows your child think he/she hears well (teacher, baby sitter, grandparent, etc.)? Does your child pay attention to a story and answer simple questions about it?

4 ­ 5 YEARS

Total

Total